| NPI | 1265060313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401417388) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417388) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-01 |
| Last Update Date | 2021-06-04 |